Contents
4.1 Introduction 77
4.1.1 Cornerstones of Restoration of Proper Musculoskeletal Function 77 4.1.2 General Time Sequence of Rehabilitation 77
4.2 Regaining Range of Motion and Flexibility 77 4.2.1 Definition of ROM 77
4.2.2 Definition of Flexibility 78
4.2.3 Essential Difference Between ROM and Flexibility 78 4.2.4 Common Causes of Joint Stiffness 78
4.2.5 Categories of Joint Stiffness 78 4.2.5.1 Intra-Articular Causes 78 4.2.5.2 Extra-Articular Causes 78 4.2.5.3 Both 78
4.2.5.4 Muscular Causes of Joint Stiffness 79
4.2.5.5 Options to Tackle Commonly Encountered Muscle Tightness 79 4.2.5.6 Techniques to Improve Flexibility 79
4.2.5.7 “Muscle Energy” Techniques 81 4.3 Muscle Strength Training 83 4.3.1 Overload Principle 83 4.3.2 Principle of Specificity 83 4.3.3 Individual Differences Principle 84 4.3.4 Reversibility Principle 84
4.3.5 Types of Muscle Strength Training 84 4.3.5.1 Isometric Training 84
4.3.5.2 Isotonic Training 85 4.3.5.3 Isokinetic Training 85
4.4 Closed Chain and Open Chain Exercises 87 4.4.1 Introduction 87
4.4.2 Differences Between Open and Closed Kinetic Chain Exercises 88 4.4.3 Definition of “Closed-Chain” Exercises 88
4.4.3.1 Advantages of Closed Kinetic Chain Exercises 88 4.4.3.2 Key Principle 88
4.4.3.3 Practical Application 88 4.4.3.4 Pitfall or Contraindication 88 4.4.3.5 Key Concept 89
Common Physical Therapy Techniques and “Alternative Medicine”
4
4.5 Training of Proprioception and Neuromuscular Control 89 4.5.1 Definition of Proprioception 89
4.5.2 Importance of Proprioceptive Training 89
4.5.3 Proper Sequence of Proprioceptive and Co-ordination/Agility Training 89 4.5.4 Proprioception Exercises 89
4.6 Biofeedback 90 4.6.1 Introduction 90
4.6.2 Definition of Biofeedback 90
4.6.3 Reports on the Clinical Use of Bio-Feedbacks 91 4.6.4 Most Popular Feedback: Myoelectric 91
4.6.5 Other Clinical Uses of These Myoelectric Signals 91 4.6.6 Principle of Use 91
4.6.7 Another Possible Mechanism 92 4.6.8 Advantages of Biofeedback 92 4.6.8.1 Use in Pain Relief 92
4.6.8.2 Use in VMO Training and in Voluntary Shoulder Dislocators 92 4.6.8.3 Use of Biofeedback in SCI 92
4.6.8.4 Posture Training in Scoliosis 92
4.6.8.5 Incorporation of Endurance and Cardiovascular Training 93 4.7 Plyometrics and Sports Training 94
4.7.1 Introduction 94
4.7.2 History of “Plyometrics” 94 4.7.3 Definition 94
4.7.4 Mechanism Behind the Use of Plyometrics 94 4.7.5 Normal Functioning of the Muscle Spindles 95 4.7.6 Normal Functioning of the Golgi Tendon Organs 95 4.7.7 Determinants of the Efficiency of Plyometrics 95 4.7.8 Metabolic Pathway Involved 95
4.7.9 Main Mechanisms Causing Power Increase 95 4.7.10 Importance of Speed 95
4.7.11 Importance of Adequate Strength 96
4.7.12 Prerequisite Before Commencing Plyometrics Training 96 4.7.13 Precautions Necessary for Plyometric Training 96 4.8 Concept of “Core Stability” 96
4.8.1 What Constitutes the “Core” 96 4.8.2 What Is “Core Stability” 96 4.8.3 Importance of Core Stability 97
4.8.4 Three Main Mechanisms of Provision of Stability 97
4.8.5 Example of the Concept of Core Stability in Patient Rehabilitation 97 4.8.6 Important Element in Rehabilitating Golf-Related Back Injuries 98 4.8.7 Anatomical Note 98
4.9 Acupuncture Therapy 98 4.9.1 Introduction 98 4.9.2 Historical Note 99 4.9.3 Popularity 99
4.9.4 Training in Acupuncture 100
4.9.5 Basic Philosophy of Chinese Medicine 100 4.9.6 Basic Philosophy of Acupuncture 100 4.9.7 Acupuncture Needles 100
4.9.8 Stimulation Method 101 4.9.9 Scope of Clinical Use 101
4.9.10 Support from Basic Science Studies 101 4.9.11 Common Side Effects 101
4.9.12 Rare Side Effects 102
4.9.13 Precautions or Contraindications 102 4.10 Massage Therapy 102
4.10.1 Introduction 102 4.10.2 Brief History 102
4.10.3 Place in the Field of Rehabilitation 102 4.10.4 Licensing and Setting of Standards 103 4.10.5 Scope of Massage Therapy 103 4.10.6 Basic Philosophy 103
4.10.7 Types of Massage Therapy 103
4.10.8 Techniques Used in the Swedish Methods 104 4.10.9 Massage Therapy Principles in Other Countries 104 4.10.10 Papers in Support of Massage Therapy 104 4.10.11 Common Precautions 104
4.11 Brief Outline of “Alternative Medicine” 104 4.11.1 Overview 104
4.11.2 Chiropractics 105 4.11.2.1 Brief History 105 4.11.2.2 Popularity 105
4.11.2.3 Licensing and Setting of Standards 105 4.11.2.4 Scope of Chiropractics 105
4.11.2.5 Basic Philosophy 105
4.11.2.6 “Mobilisation” vs “Manipulation” 106
4.11.2.7 Goal of Modern Chiropractics (Using LBP as an Example) 106 4.11.2.8 Spinal Manipulative Therapy 106
4.11.2.9 Papers in Support of SMT in Back Pain Treatment 106 4.11.2.10 Possible Mechanism of SMT (Author’s View) 107 4.11.2.11 Limitations and Contraindications 107
4.11.2.12 The Future 107
4.11.3 Osteopathic Medicine 107 4.11.3.1 Brief History 107 4.11.3.2 Popularity 108
4.11.3.3 Licensing and Setting of Standards 108 4.11.3.4 Scope of Osteopathic Medicine 108 4.11.3.5 Basic Philosophy of Osteopathic Practice 108 4.11.3.6 Basic Philosophy of Osteopathic Manipulation 108
a Contents 75
4.11.3.7 Goal of Modern Osteopathic Medicine (Using Musculoskeletal Pain as an Example) 109
4.11.3.8 Papers in Support of Osteopathic Manipulation Therapy 109 4.11.3.9 Limitations 109
4.11.3.10 The Future 109 General Bibliography 110
Selected Bibliography of Journal Articles 110
4.1 Introduction
n This chapter reveals the key and common physical therapy techniques used in orthopaedic rehabilitation
n They are presented in the order of the time sequence of administra- tion in most rehabilitation protocols
n The important technique of proprioceptive neuromuscular facilitation (PNF) is discussed in Chap. 11, while Sects. 4.11.2 and 4.11.3 touch on chiropractics and osteopathic medicine respectively
4.1.1 Cornerstones of Restoration of Proper Musculoskeletal Function
n Proper limb alignment and biomechanics
n Proper joint kinematics, stability and proprioception
n Proper neuromuscular control including sequence of firing (among individual muscles and between different functional groups)
n Proper length–tension relationships
n Proper force couples
n Proper pain management
4.1.2 General Time Sequence of Rehabilitation
n Regain range of motion (ROM) and flexibility, pain and oedema con- trol
n Training of muscle strength
n Proprioception and neuromuscular control training
n Endurance training added (and circuit training)
n Co-ordination and motor re-learning
n Sports- (or job-) specific training, plyometrics
4.2 Regaining Range of Motion and Flexibility 4.2.1 Definition of ROM
n Range of motion refers to movement of a body part through a partic- ular joint’s complete, unrestricted, normal motion (according to Hey- ward)
a 4.2 Regaining Range of Motion and Flexibility 77
4.2.2 Definition of Flexibility
n Flexibility refers to the musculotendinous unit’s ability to elongate with the application of a stretching force (according to Heyward) 4.2.3 Essential Difference Between ROM and Flexibility
n It can be seen that ROM mainly refers to movement of a joint, while
“flexibility” is based on concepts of muscle stretching 4.2.4 Common Causes of Joint Stiffness
n Stiffness of joints may originate from different structures, including the articulating bone surfaces, joint capsule, ligament, muscle, tendon, subcutaneous tissue and even skin
n The following classification is preferred for clarity 4.2.5 Categories of Joint Stiffness
n Intra-articular
n Extra-articular
n Both
4.2.5.1 Intra-Articular Causes
n Congenital, e.g. bony dysplasia
n Acquired, e.g. previous fracture
(In this chapter, we will only concentrate on discussion on regaining
“flexibility” from muscle tightness rather than discussing intra-articu- lar causes of joint stiffness. The use of machines like the continuous passive motion (CPM) will be discussed in Chap. 14)
4.2.5.2 Extra-Articular Causes
n Skin – e.g. hypertrophic burn scarring (Chap. 13)
n Soft tissue – e.g. ectopic calcification, burns and rarer causes like fi- brodysplasia ossificans progressiva (with heterotopic ossification)
n Muscle – e.g. “functional” like reactive muscle spasm due to local painful condition, muscle imbalance from poor training, and other, rather less common, causes like myositis ossificans
4.2.5.3 Both
n In fact, any long-standing joint stiffness can influence extra-articular structures that create further stiffness, e.g. (adhesions between myo-
fascial planes) and the initially unaffected joint structures like liga- ments and capsules can lose elasticity or in fact shorten by relative immobility
n Conversely, any long-standing extra-articular causes of joint stiffness can have a significant influence on the joint itself or its kinematics (e.g. kinetic chain dysfunction), see Chap. 9
4.2.5.4 Muscular Causes of Joint Stiffness
n Common: causes like poor posture, poor training techniques in ath- letes causing neuromuscular imbalance and muscle tightness, and joint stiffness
n Rarer causes:
– Myositis ossificans
4.2.5.5 Options to Tackle Commonly Encountered Muscle Tightness
n Muscle stretching exercises – Static stretches
– Ballistic stretches
n Muscle energy techniques1
4.2.5.6 Techniques to Improve Flexibility
4.2.5.6.1 Muscle Stretching Techniques: General Rationale
n Stretching to effect muscle lengthening is based on the principle of:
– Muscle autogenic inhibition
– With prolonged stretching, viscoelastic and/or plastic change can occur in the connective tissue elements that have elastin and col- lagen
n The contractile actin-myosin elements respond more to high-velocity deforming forces, while the connective tissue non-contractile portion responds mainly to the degree of stretch
a 4.2 Regaining Range of Motion and Flexibility 79
1The technique of PNF is based on somewhat similar principles, but since this tech- nique is best suited to patients with neuromuscular disorders (after Knott and Voss) it will be discussed under the section on cardiopulmonary (CP) rehabilitation in- stead
4.2.5.6.2 Pre-Requisite Before Stretching
n Adequate warm-up is needed to increase core temperature, easing the deformability of the connective tissue elements
n Most recommend warming up to 1038F 4.2.5.6.3 Static Stretches
n Involve stretching the muscle in question in a position that allows for maximum stretching and hold there for 15–30 s
n Advantage: less chance of injury than ballistic stretching, and does not usually cause delayed onset muscle soreness
n Disadvantage: in stretching the upper limb, can need an assistant or instrument to perform
4.2.5.6.4 Ballistic Technique
n This usually involves jerking and bouncing movements, usually of the lower limb
n Disadvantage: may cause injury if not adequately warmed up or pre- ceded by static stretch; the timing may not be adequate for the Golgi tendon to fire its inhibitory reflex
4.2.5.6.5 Combined Use of Cryotherapy and Stretching
n This was discussed under the section on cryotherapy in Chap. 2
n Cold stretching can sometimes be effective in managing delayed onset muscle soreness
4.2.5.6.6 Others
n See “muscle energy” techniques in the following discussion
n As mentioned, PNF techniques are best described for rehabilitation of patients with neuromuscular disorders, and will be described separa- tely
4.2.5.6.7 General Precautions for Stretching
n Patient must be relaxed and preferably seated
n Do not attempt ballistic stretches without adequate warm-up and stat- ic stretches, do not commence these exercise if there is recent injury to the musculotendinous unit
n Avoid overdoing the muscle stretches to the point of pain
4.2.5.7 “Muscle Energy” Techniques 4.2.5.7.1 Definition
n Muscle energy techniques is a type of manual muscular stretching technique based on sound neurophysiology and involves ways of re- laxing and stretching overly active muscles
n This technique can be useful in tackling complex dysfunction of the kinetic chain
4.2.5.7.2 Rationale of Using Muscle Energy Techniques
n Many a times when a group of muscles becomes tight or overactive (produced by, e.g. poor posture, abnormal nearby joint kinematics, or improper training techniques in athletes) it may cause an abnormal length–tension relationship of the kinetic chain, and also produce concomitant weakness of antagonist by reciprocal inhibition, and ab- normal compensatory firing of associated synergistic musculature
n Muscle energy techniques attempt to relax overactive muscles, stretch over-tight muscles or shortened muscles, and prevent the complica- tions of altered neuromuscular control and firing of the muscles of the kinetic chain; also prevents unwanted inhibition of the antagonist of the overactive musculature
4.2.5.7.3 Main Underlying Neurophysiological Principles
n Principle 1: post-contraction inhibition
n Principle 2: reciprocal inhibition Principle 1: Post-Contraction Inhibition
n This makes use of the observation in neurophysiology that after a muscle contracts, it will be rendered in a more or less relaxed status for a brief period of around half a minute, which provides a “window of opportunity” for the therapist or the surgeon to stretch it
Principle 2: Reciprocal Inhibition
n The principle of “reciprocal inhibition” states that upon contraction of a muscle, its antagonist will be reciprocally inhibited
n This is a normal physiological phenomenon that helps to allow proper and smooth functioning of the kinetic chain
n This can be put to good use to help relax the overactive agonist
a 4.2 Regaining Range of Motion and Flexibility 81
4.2.5.7.4 Common Indications for Muscle Energy Techniques
n Dysfunction of the kinetic chain, the main underlying cause of which is not mainly due to alignment problems, bony deformity, or joint in- stability
n Useful in managing many problems of the kinetic chain in both ama- teur and professional athletes, e.g. involved in jumping sports like bas- ketball or in running
4.2.5.7.5 Tricks for Proper Performance of Muscle Energy Techniques
n Identify the point in the ROM at which resistance is first encountered
n Effect agonist contraction at 25% strength while the therapist resists the isometric contraction for about 10 s
n During the window of opportunity that follows as aforementioned, the agonist is stretched
n Patient uses the antagonist to effect further inhibition of the agonist to achieve further improvement in the ROM
4.2.5.7.5 Clinical Examples: Tight Gastrocnemius
n Tight gastrocnemius is rather common; causes include:
– Pathology in the tendon proper, e.g. Achilles tendinitis – High heeled shoes in women
– Painful heels, e.g. plantar fasciitis – Gait anomalies
– Flexed posture of the hip or knee – Painful ankle, etc.
4.2.5.7.6 Effect of Tight Gastrocnemius
n Can affect nearby subtalar joint, or Chopart’s joint
n Gait anomalies (affect first and second rockers)
n Altered shock absorption, and increased force transmission up the ip- silateral kinetic chain (ankle, knee, hip)
n Sometimes predispose to back and sacroiliac joint (SIJ) discomfort 4.2.5.7.7 Application of Muscle Energy Techniques
n Put your relaxed patient supine on the couch
n Ensure ipsilateral subtalar joint is neutral
n Ankle dorsiflexion (thus stretching the Achilles tendon) up to first point of passive resistance
n Patient asked to actively perform ankle plantar flexion at 25% of max- imum strength (i.e. agonist firing)
n Continue agonist firing for 10 s
n Then ask patient to actively perform ankle dorsiflexion (i.e. firing of antagonist) until a new improved ROM is achieved
4.2.5.7.8 Precautions
n Patient education: patient taught to continue stretching exercises at home; both warm-up and warm-down are needed
n Concomitant training of the patient in techniques of proper core exer- cises and neuromuscular stabilisation training
4.3 Muscle Strength Training
n General principle of muscle strength training (according to Geffen) – Overload principle
– Specificity principle
– Individual differences principle – Reversibility principle
4.3.1 Overload Principle
n Overloading a muscle can be effected by an increase in frequency of training or its intensity or duration
n The overload principle involves exercise that is carried out at a level greater than that to which an individual has been accustomed, in or- der to achieve gains in physiological function
4.3.2 Principle of Specificity
n Another name of this principle is specific adaptation to imposed de- mand (SAID)
n During the later stage of rehabilitation of athletes for example, the in- dividual needs to simulate the task required of the sport (sport-specif- ic) in order to optimise the neural firing pattern and timing of the re- quired task
a 4.3 Muscle Strength Training 83
4.3.3 Individual Differences Principle
n This essentially highlights the fact that rehabilitation of patients should not be in a stereotyped or cook-book fashion; with due con- sideration paid to individual differences in, say, preoperative fitness, time lapse between surgery and the start of rehabilitation, and gender differences, etc.
4.3.4 Reversibility Principle
n Even strong athletes can suffer from the phenomenon of “detraining”
since gains from exercise can be rapidly lost within a few months of exercise cessation (Jeffreys, 2002), sometimes even earlier
4.3.5 Types of Muscle Strength Training
n Isometric
n Isotonic
n Isokinetic
4.3.5.1 Isometric Training
n Method of muscle strengthening where despite the fact that the mus- cle is contracting, there is no change in length or joint angle (Komi 1992)
n Commonly employed mode of rehabilitation in early phase of rehabi- litation
n Another advantage is no need for expensive equipment
4.3.5.1.1 Why Strength Can Improve with Isometrics Without Motion
n Due to the 208 physiologic overflow that accompanies this type of training
4.3.5.1.2 Key Concept
n Isometric exercises are joint angle-specific; thus, gains in strength only occur within a small range of motion corresponding to the joint angle at which the contraction is undertaken
4.3.5.1.3 Disadvantage/Caution
n Avoid doing the Valsalva during isometric training, or BP may in- crease
n This type of training needs to be done under supervision since pa- tient may overload the healing structures
4.3.5.2 Isotonic Training
n A typical example is the use of free weights where the load is con- stant, but the speed of motion varies
n Isotonic muscle activity can be subdivided into concentric and ec- centric movements
4.3.5.2.1 Disadvantage of Isotonics
n Muscle is maximally loaded at its weakest point in the range of mo- tion; thus, not safe to perform this kind of exercise in the early post- operative period
n But for the rest of the ROM the muscle can be under-loaded
n May induce unnecessary pain
n Injury can result from falling weights or by weights that exceeded the limits of the muscle
4.3.5.3 Isokinetic Training
n Isokinetic contraction is featured by contraction at a pre-defined rate and usually performed using special machines like a dynamometer (Figs. 4.1, 4.2)
4.3.5.3.1 Key Concept
n It works by the principle of “accommodative resistance”
n The patient connected to the isokinetic machine encounters a resis- tance no greater than the amount of force applied to the muscle, per-
a 4.3 Muscle Strength Training 85
Fig. 4.1. Machine for isokinetic training
mitting the muscle to exert its own maximum force and strength throughout an ROM
n The machine keeps the angular velocity of the moving limb constant by changing the force generated by the isokinetic machine to resist the intended movement
4.3.5.3.2 Main Advantages
n Can be applied relatively early on in the rehabilitation of many sports injuries
n Forces generated are usually well tolerated by the soft tissues and the joint
n Thus, less chance of re-injury
n Provides an objective measurement of dynamic strength for better documentation and comparison between different methods
n Allows the muscle to exert its maximum strength throughout the ROM
n Isokinetic testing can help identify the cause of the patient’s (espe- cially an athlete’s) problem, e.g. by use of torque analysis
n Data collected serially (and on both sides for comparison) are useful for imparting decisions on the progress of rehabilitation
Fig. 4.2. Close-up of another isokinetic machine preparing to initiate training for this patient after anterior cruciate ligament reconstruction
n In short, on the one hand avoidance of undue stresses on the joint, and yet can avoid excessive maximum dynamic loads
4.3.5.3.3 Details of Isokinetic Training
n It is best to test the type of motion the patient performs in daily life, and (in the case of the athlete) reproduce the plane of motion pertain- ing to his sports
n The machine needs calibration before use and monthly thereafter
n Minimise motion above and below the joint in question
n Adequate warm-up
n Give rest interval between each test of about 2 min
n Test speed depends on the joint in question – in general higher for knees and shoulders and low for ankles and wrist, etc.
n Each training session consists of around ten exercise repetitions 4.3.5.3.4 Recording of Data
n Traditional method: the details of reporting are outside the scope of this book, but we are mainly interested in looking at parameters like average power, peak torque and total work
n New isomapping method: essentially a method that involves graphical representation plus qualitative analysis of neuromuscular perfor- mance. Like the traditional method, it can help identify, say, in which muscle group or contraction mode or in which part of the ROM the problem lies (Med Sci Sports Exerc 2000)
4.4 Closed Chain and Open Chain Exercises 4.4.1 Introduction
n Closed kinetic chain rehabilitation protocol is commonly used and started early in many rehabilitation protocols
n Most applications in the past have been used for LL rehabilitation (e.g. with the feet on the ground), although it is now increasingly used in UL rehabilitation as well
a 4.4 Closed Chain and Open Chain Exercises 87
4.4.2 Differences Between Open and Closed Kinetic Chain Exercises
n Open-chain: refers to those exercises in which the distal end or termi- nal of the chain is freely mobile and not loaded, e.g. back extension exercises against gravity
n Closed-chain: here, the distal end or terminal is immobile or loaded 4.4.3 Definition of “Closed-Chain” Exercises
n Those in which the distal (terminal) end of the lower or upper limb is kept immobile or being loaded with considerable resistance
4.4.3.1 Advantages of Closed Kinetic Chain Exercises
n Simulate more normal biomechanical and physiologic function
n Little shear stress across the injured joint or peri-articular soft tissue
n Provision of proprioceptive stimuli 4.4.3.2 Key Principle
n The force and transmission of closed kinetic chain exercise works on the principle of summation of speed
n According to Putnam (J Biomech 1993), the total energy of force in the closed kinetic chain is a summation of the contributions of the individual segments of the kinetic chain
4.4.3.3 Practical Application
n Keys to success besides ensuring the distal end of the kinetic chain is loaded or stationary:
– Small joint movements – Decreased joint shear – Proprioceptive stimulation
– Dynamic joint stabilisation through muscle co-contraction
– Translation of instantaneous centre of motion should occur in a predictable manner based on the local biomechanical forces at work
4.4.3.4 Pitfall or Contraindication
n May not work if there is an altered sequence of firing of the muscles in the kinetic chain
4.4.3.5 Key Concept
n Importance of rehabilitating the whole kinetic chain in sports injury cannot be over-emphasised, see the section on rehabilitation in sports injury in Chap. 9
4.5 Training of Proprioception and Neuromuscular Control 4.5.1 Definition of Proprioception
n Proprioception involves aspects of joint position sense, sensing of mo- tion, vibration and pressure via mechanoreceptors located in joints, li- gaments and musculotendinous units
n It is sometimes also referred to as the “somatosensory system” and is made up of muscle spindles, Golgi tendon organs and joint/skin re- ceptors (Hogblum, 2001)
4.5.2 Importance of Proprioceptive Training
n There is an increasing trend toward emphasising proprioceptive train- ing in rehabilitation of the kinetic chain (Fig. 4.3). Moreover, training should start as early as possible after commencement of weight-bear- ing (Kinch, 2001)
n This is because diminished afferent proprioceptive input can deacti- vate coordinated neuromuscular activation
n If severe, the functional effects can be comparable to actual anatomic disruption of the ligament or tendon (Laskowski, 1997)
4.5.3 Proper Sequence of Proprioceptive and Co-ordination/Agility Training
n It is essential to note that re-training of proprioception and balance should precede coordination training
n Agility training can only start after training of proprioception and later coordination
4.5.4 Proprioception Exercises
n Should proceed from simple to complex
n Slowly progressing in degree of difficulty, e.g. from one-leg stands, to wobble board, to mini-trampoline, etc.
n Further discussion of this topic will be found in Chaps. 9 and 19 a 4.5 Training of Proprioception and Neuromuscular Control 89
4.6 Biofeedback 4.6.1 Introduction
n Neuromuscular control will be discussed in Chap. 9
n But we will take this opportunity to describe yet another technique, i.e. biofeedback
4.6.2 Definition of Biofeedback
n The technique of using electronic equipment to reveal to humans their internal physiologic events, usually in the form of visual or audi- tory signals
Fig. 4.3. Machine for proprioceptive training
n With an aim to teaching them the way to manipulate these otherwise involuntary events by the manipulation of displayed signals (Basma- jian et al., Arch Phys Med Rehabil 1975)
4.6.3 Reports on the Clinical Use of Bio-Feedbacks
n Field of orthopaedics
– SCI patients and posture training in scoliosis – Retraining hand function after tendon transfer
– Retraining the proper firing of muscle as in voluntary shoulder dis- locators
– Retraining the vastus medialis obliquus (VMO) of the knee – Pain control
n Other fields
– Relaxation therapy
– Stroke patient rehabilitation
– Possible effect on heart rate and blood pressure 4.6.4 Most Popular Feedback: Myoelectric
n Here, the myoelectric signals from the muscle are translated into acoustic and visual signals, as in buzzing sounds and lights
n Usually displayed as spikes on a cathode ray oscilloscope or as pop- ping noises on a loudspeaker
4.6.5 Other Clinical Uses of These Myoelectric Signals
n These signals can also be put to good use in other clinical areas such as the control of myoelectric prostheses
n Myoelectric prostheses are discussed in Chap. 10 4.6.6 Principle of Use
n One of the great advantages of biofeedback = enables small changes in the correct direction to be detected and rewarded as success so that with time these build up into larger changes
n Patients may ultimately be able to learn to perceive these changes in the absence of the instruments and practice themselves
a 4.6 Biofeedback 91
4.6.7 Another Possible Mechanism
n Occasionally, the extreme plasticity of the nervous system may allow the individual to learn to use alternative pathways that bypass the faulty tissue (JAMA 1985)
4.6.8 Advantages of Biofeedback
n Acts as a form of encouragement and motivation
n Engenders a coping response and helps alleviate stress
n Many patients feel the technique improves his or her own recognition of the clinical problem at hand
n Increased confidence 4.6.8.1 Use in Pain Relief
n Tracts were discovered in the brain, which, when stimulated in un- anaesthetised animals, can effectively relieve pain
n The stimulation of these tracts is believed to produce opiate-like sub- stances and have in the past had variable success in the relief of some patients with chronic excruciating and intractable pain. Whether oc- casional reports of pain relief with biofeedback uses these pathways needs further research
4.6.8.2 Use in VMO Training and in Voluntary Shoulder Dislocators
n Here, the patient will relearn to:
– Contract the correct muscle or muscle groups
– Or to strengthen the weakened or atrophied muscle, in this case the VMO
4.6.8.3 Use of Biofeedback in SCI
n Chronic SCI with little neuromuscular activity are probably not good candidates
n Refer to discussion in Chap. 12 on SCI
n Requires extra motivation from patient, very labour-intensive 4.6.8.4 Posture Training in Scoliosis
n New training devices can be worn under the clothes without move- ment restraints (Wong et al., Prosthet Orthot Int 2001). When the pa- tient is not in a good posture for, say, 20–30 s, an audible sound will be made, but this ceases upon restoration of a better posture:
– The general move towards the miniaturisation of electronic devices provides the potential to provide the patient with training in the friendly home environment
– Newer training devices can readily be worn by the patient and readily incorporated in daily life
4.6.8.5 Incorporation of Endurance and Cardiovascular Training 4.6.8.5.1 Endurance vs Strength Training
n Alongside the rehabilitation programme, a fitness schedule is required to allow the patient to maintain cardiovascular fitness and muscular endurance
n To promote cardiorespiratory adaptations, use of dynamic exercises involving contractions of large muscle groups need be performed over an adequate period with sufficient oxygen or aerobic exercise and un- der guidelines as set out by the American College of Sports Medicine (ACSM 1990). A detailed comparison of endurance vs strength train- ing is given in Chap. 9.
4.6.8.5.2 Circuit Training
n Newer regimens like “circuit resistance training” (where the individu- al goes through a number of stations training both strength and endurance) that de-emphasise the traditional, very brief intervals of heavy muscle strengthening in standard resistance training protocols are gaining in popularity
n This is because this form of training provides a more general condi- tioning, with demonstrated improvements in body composition, mus- cle endurance and strength, as well as cardiovascular fitness (Haennel, Med Sci Sports Exerc 1989)
n In addition, circuit resistance training also provides supplementary off-season conditioning even for sportsmen and women who demand high levels of strength and power. There will be more discussion in Chaps. 9 and 19
4.6.8.5.3 Timing of Cardiovascular Conditioning
n Total body aerobic conditioning should be initiated as early as possi- ble after injury or surgery if this does not aggravate pain or impair healing
a 4.6 Biofeedback 93
n This minimises effects of disuse and also has a positive psychological impact on our patients
n Timing and administration of endurance training and the way to in- corporate with strength training if your patient is a professional ath- lete will be discussed in Chap. 9
4.7 Plyometrics and Sports Training 4.7.1 Introduction
n Plyometrics is only one of the different methods of preparing the ath- lete to return to sports or even competition
n Other adjuncts include fast-velocity isokinetic and isotonic training, sports-specific muscle conditioning and strength training, and agility exercises
4.7.2 History of “Plyometrics”
n The term literally means “to increase”, translated from Greek
n This technique of training is well known to have been applied to the jumping sports, but now the term usually encompasses any type of exercise utilising the stretch reflex to increase the power output of the contracting muscle
4.7.3 Definition
n Essentially a form of training, usually in athletes, consisting of com- bined strength and speed training
n This may also form part of the late rehabilitation of injured athletes in preparation for their return to the field or athletic arena
4.7.4 Mechanism Behind the Use of Plyometrics
n Normal movement patterns of the musculoskeletal system work by stretch-shortening cycles of muscle
n The technique of plyometrics works by pre-stretching the muscle and activating the stretch-shortening cycle, causing a more powerful sub- sequent concentric contraction
n Energy stored in the pre-stretch will be released as kinetic energy in an opposite direction, and if applied correctly will result in an explo- sive movement
4.7.5 Normal Functioning of the Muscle Spindles
n Muscle spindles are parallel to the muscle fibres; they fire in response to stretch and the impulse goes to the brain, which ultimately results in muscle contraction
n The firing is increased with more rapid muscular stretch 4.7.6 Normal Functioning of the Golgi Tendon Organs
n The Golgi tendon organs are in series and embedded in the tendon;
they fire when there is increased tension in the tendon and induces an inhibitory reflex to prevent tension build-up – with inhibitory sig- nals sent to the muscle, which contracts, and its synergists
4.7.7 Determinants of the Efficiency of Plyometrics
n Increased effectiveness with decreased interval between lengthening and shortening
n Rate of stretch
n Degree of stretch – which depends on magnitude of stretch force, the extent of firing of muscle spindles, and the strength of individual fi- bres
n It is believed that prolonged training can raise the firing threshold of the Golgi tendon organs, allowing enhanced force generation
4.7.8 Metabolic Pathway Involved
n Plyometrics mainly involves anaerobic pathways
n Adequate rest between sessions is warranted 4.7.9 Main Mechanisms Causing Power Increase
n Shortening the time interval between the eccentric contraction and the subsequent concentric contraction (Acta Physiol Scand 1979)
n Usually, fast-twitch muscle fibres are involved 4.7.10 Importance of Speed
n This has just been discussed
n Speed improvements may be partly due to improved and additional recruitment of motor units
a 4.7 Plyometrics and Sports Training 95
4.7.11 Importance of Adequate Strength
n Plyometrics training will not succeed in the absence of adequate strength
n Also, increased muscle strength and cross-sectional area allows great- er storage of energy not only in the contractile unit, but also in the elastic connective tissue elements
4.7.12 Prerequisite Before Commencing Plyometrics Training
n Adequate flexibility and warm-up
n Adequate strength and muscle cross-sectional area
n Stable base and proper alignment and stability of the kinetic chain (including static and dynamic stability)
4.7.13 Precautions Necessary for Plyometric Training
n Adequate rest
n Periodisation among strength training, plyometric training, general conditioning (while off season), in addition to sports-specific training
n Beware of over-training, adequate nutrition and fluid replenishment, prevent boredom by introducing variability of training manoeuvres
4.8 Concept of “Core Stability”
4.8.1 What Constitutes the “Core”
n The “core” is composed of the lumbar vertebrae, the pelvis, and hip joints, together with the active and passive structures that either pro- duce or restrict movements of these motion segments
4.8.2 What Is “Core Stability”
n “Core stability” refers to the ability of the lumbopelvic hip complex to prevent buckling and to return to equilibrium without perturbation.
This is mainly dependent on the active structures consisting of con- tractions or co-contractions of the muscles, since the stiffness of the lumbopelvic hip complex has been shown in the past to be mainly de- pendent on the active stabilisers for its stiffness as opposed to passive stabilisers
n Core stability is also dynamic; hence, the local anatomy must be able to continually adapt to changing postures and loading conditions in
order to maintain the integrity of the vertebral column thus providing a stable base for the extremities
4.8.3 Importance of Core Stability
n Contraction of the muscular elements of the core can increase the stiffness of the hip and trunk. To achieve stability, not only is the ability of co-contraction of the antagonistic trunk muscles required (in response to anticipated spinal loading), but the contraction of the hip and trunk muscles must also be coordinated, as prolonged co- contraction is also detrimental and may lead to excess compressive loading to the system
n Another important factor underscoring the importance of core stabili- ty is that although normal trunk muscle reflexes are automatic and may stiffen the spine for loading, this system tends to have an innate neuromuscular delay and may offer inadequate protection in the face of a sudden spinal load, thus underscoring the importance of training of core stability
4.8.4 Three Main Mechanisms of Provision of Stability
n Increased intra-abdominal pressure can be effected by simultaneous contraction of the diaphragm and the pelvic floor muscles, or by ab- dominal muscles, particularly the transversus abdominis
n Increased axial load can be effected by muscle co-contractions of the trunk extensor and flexor muscle groups
n The large, superficial muscles of the hip and trunk are architecturally best suited to producing movement and increasing hip and trunk stiffness to counteract destabilising forces during functional activities 4.8.5 Example of the Concept of Core Stability
in Patient Rehabilitation
n Example: back injury in a game of golf, due to poor technique, over- swing, improper warm-up or improper equipment
n The golf swing has four components: take-away, acceleration, impact and follow-through
n During the swing, trunk rotation and high shear forces can cause in- jury to the thoraco-lumbar spine, thus causing back pain
a 4.8 Concept of “Core Stability” 97
4.8.6 Important Element
in Rehabilitating Golf-Related Back Injuries
n Pain relief
n Training in flexibility
n Training in core stability
n Proper coaching and warm-up
n Proper technique and equipment 4.8.7 Anatomical Note
n Anatomically, the chief muscles that function in the sagittal plane in- clude the rectus abdominis, transversus abdominis, erector spinae, mul- tifidus and hamstrings. The rectus abdominis and multifidus, together with tonic contraction of the transversus, can produce increases in in- tra-abdominal pressure. The gluteus maximus is important to help transfer lower extremity forces to the trunk. Chief lateral muscles of the hip and trunk that function in the frontal plane include gluteus medius, gluteus minimus and quadratus lumborum. These glutei help maintain a level pelvis in closed chain motion. Co-contraction of bilat- eral quadratus lumborum help stiffens the spine. Chief medial muscles acting in the frontal plane include adductor magnus, adductor longus and brevis, and pectineus. Their role in core stability is smaller than that of the aforementioned muscles. Trunk rotation is provided for by internal and external oblique muscles, the iliocostalis lumborum and the multifidus. Bilateral activation of these muscles also aids core stabil- ity by increasing intra-abdominal pressure
4.9 Acupuncture Therapy 4.9.1 Introduction
n As acupuncture therapy (Fig. 4.4) is increasingly used by physiothera- pists and other health professionals (either alone or as part of a treat- ment programme) in the US and abroad, it will not be included under Sect. 4.11 on alternative medicine
n It is interesting that despite being based on theories very different from western medicine, acupuncture has now received wide clinical acceptance because it has been proven to be efficacious in both clini- cal and basic science research
n In fact Melzack, the originator of the gate theory of pain, found a 70% correlation between acupuncture points and trigger points used in the treatment of myofascial pain (Melzack et al., Pain 1977) 4.9.2 Historical Note
n First practised in China > 2 millennia ago, with published works in writing around 100 BC
n Owing to significant differences from western medicine theories, it was not popularised in US until the 1970s
n Currently has a well-accepted place in US after the NIH consensus de- velopment conference on acupuncture with well-proven efficacy in postoperative pain, postoperative dental pain and chemotherapy-in- duced vomiting (J Am Med Assoc 1998)
4.9.3 Popularity
n All along has been popular in Asian countries, and increasingly popu- lar in USA and other western nations
n Practised by both physiotherapists, acupuncturists, and some tradi- tional Chinese medicine practitioners
a 4.9 Acupuncture Therapy 99
Fig. 4.4. Electro-acupuncture therapy at work
n Owing to increasing acceptance in US, some insurance companies are willing to cover costs incurred in acupuncture treatment
4.9.4 Training in Acupuncture
n Most USA states use the National Commission for Certification of Acupuncturists (NCCA) standards during certification
n Most licensed acupuncturists need to go though 3 years of training
n It is interesting to note that virtual reality was reportedly being used to help teach acupuncture in some centres (IEEE Trans Inf Technol Biomed 2006)
4.9.5 Basic Philosophy of Chinese Medicine
n Basic thinking includes:
– Concept on yin vs yang: these two opposing forces need to be bal- anced. A good balance of yin–yang is needed to promote the flow of “chi” which is essentially visualised as a form of energy. Illness will result if there is an abnormal flow of “chi” through the body’s meridians
– Concept of five elements including fire, earth, metal, water and wood. Their correct dynamic interaction is needed for health 4.9.6 Basic Philosophy of Acupuncture
n The flow of “chi” can be potentially restored by needle insertion at some of the acupuncture points (a total of 365 in the body)
n One needs to select the correct point combinations, have the correct technique, correct positioning, and correct depth in order for the treatment to work
n Several treatment sessions or even longer periods are needed depend- ing on the condition treated
4.9.7 Acupuncture Needles
n Traditionally used needles in the distant past in the times of the em- perors were made of gold
n The fine needles used nowadays are made of stainless steel, most are reusable upon proper sterilisation to prevent disease transmission
4.9.8 Stimulation Method
n Traditional needles are in involved various methods, e.g. twisting, twirling, lift-and-thrust techniques, etc.
n Some centres use both low (2 Hz) and high frequency (100 Hz) elec- trical stimulation to accompany the needling procedure – “electrical acupuncture”
4.9.9 Scope of Clinical Use
n Acute pain, e.g. postoperative dental pain, and after abdominal sur- gery (Pain 2002)
n Chronic pain and reflex sympathetic dystrophy (RSD; see Chap. 15)
n LBP (Furlan et al., Spine 2005)
n SCI (see Chap. 12)
n Cerebrovascular accident (Sze et al., Stroke 2002)
n Nausea and vomiting (Vickers, JR Soc Med 1996)
n Psychological disturbance, e.g. depression (Psychol Sci 1998), and sleep disturbances
n Neck disorders (Trinh et al., Cochrane Review 2006, CD004870) 4.9.10 Support from Basic Science Studies
n On pain relief: three possible mechanisms:
– By the gate theory (see Chap. 15)
– By endogenous opioid peptides (Acta Physiol Scand 1977) and re- versal by naloxone (Brain Res 1977)
– By descending pain inhibitory pathways (Pain 1987)
n On possible effects on higher centres besides spinal cord, e.g. higher brain centres that can be stimulated include:
– Limbic system by functional MRI studies (Human Brain Mapping 2000)
– Pituitary–hypothalamus area and midbrain (according to Pomeranz 1987)
4.9.11 Common Side Effects
n Pain especially if needle inserted in incorrect position
n Bruising
n Infection
n Tiredness
a 4.9 Acupuncture Therapy 101
4.9.12 Rare Side Effects
n Pneumothorax
n Aggravating the presenting systems
n Systemic feeling of being unwell
n Syncope and even more serious effects (White et al., BMJ 2001) 4.9.13 Precautions or Contraindications
n If using reusable needles, need proper sterilisation
n A small number of patients develop significant systemic sickness after the start of acupuncture; they should preferably avoid the use of this therapy
n Therapist with newly acquired acupuncture skills should ideally be supervised by colleagues experienced in this technique
4.10 Massage Therapy 4.10.1 Introduction
n Since many physiotherapists use massage therapy, myofascial and trigger point techniques in their daily practice, this form of therapy is arbitrarily not grouped under “alternative medicine” in this book
n The number of professional massage therapists in the USA is increas- ing and estimated to be 200 000, according to the American Massage Therapy Association
4.10.2 Brief History
n The roots of massage therapy lie in the oldest of civilisations, e.g.
Chinese, Greek, Egyptians centuries ago
n The more widely used modern Swedish techniques originated from the works of Per Henrik Ling in the early 18th century based on ideas of proper motion and massage to benefit the lymphatic and circula- tory systems
4.10.3 Place in the Field of Rehabilitation
n Massage therapy is widely practiced by many health professionals e.g.:
– Professional massage therapist – Physiotherapist
– Physiotherapist assistants
– Some orthopaedic nurses – Some osteopathic practitioners – Some chiropractors
4.10.4 Licensing and Setting of Standards
n Only 30 out of 50 US states require formal licensing
n Abundant massage training courses in USA and other countries
n Some US states offer professional degree courses in bodywork and massage therapy
4.10.5 Scope of Massage Therapy
n Majority of patients going to seek massage therapists are suffering from musculoskeletal disorders or desire feelings of wellness or re- laxation
n As discussed, massage therapy techniques are used by many different fields of different health care professionals
4.10.6 Basic Philosophy
n This varies somewhat from that of the country of origin
n Most are based on:
– Movement re-education to obtain a more normal kinesiology – Superficial and deep massage techniques to effect relaxation, pain
relief, improve circulation among other effects
– Accompanied by exercise, energy techniques and stresses the ade- quacy of fluid intake
– Beliefs in the philosophy of aiding the body to heal itself
– Finally, deep massage therapy is aimed at tackling restricted mo- tion, pain relief and myofascial trigger point release
(Discussion of trigger points and myofascial pain syndrome closely follows this discussion)
– There are some claims regarding positive effects on digestive, im- mune and hormonal systems
4.10.7 Types of Massage Therapy
n The majority of massage therapy techniques practiced in the USA tend to follow the Swedish techniques
n Other countries have other techniques based on different underlying ideas or philosophies
a 4.10 Massage Therapy 103
4.10.8 Techniques Used in the Swedish Methods
n Petrissage – including kneading and lifting
n Effleurage – gliding movements
n Friction – involves “moving the layers under the skin”
n Percussion
n Vibration
4.10.9 Massage Therapy Principles in Other Countries
n India: stresses the combined use of oil and hand to restore the flow of energy
n China: stress on treating imbalance of body’s energy or “chi”. Tech- niques include acupressure, tuina, etc.
n Japan: popularised a type of finger pressure called “shiatsu”, essen- tially a variety of acupressure
4.10.10 Papers in Support of Massage Therapy
n In a recent Cochrane Collaboration review of nine previous publica- tions (Spine 2002) the effectiveness of massage therapy for LBP was assessed
n In many studies in the Cochrane review, massage therapy was found to be superior to relaxation therapy, acupuncture and education, but seemed less efficacious than TENS and spinal manipulation
4.10.11 Common Precautions
n Infected field
n Tumour
n Bleeding tendency
n Extreme osteoporosis
n Insensate skin
n Instability or fracture of local musculoskeletal structures
4.11 Brief Outline of “Alternative Medicine”
4.11.1 Overview
n As orthopaedic surgeons, we frequently encounter patients having sought treatment by chiropractors or osteopathic practitioners prior to their clinic visit; it therefore pays to have a brief outline of the methods of treatment of the practitioners of these disciplines
4.11.2 Chiropractics 4.11.2.1 Brief History
n It was Daniel David Palmer who performed the first chiropractic ma- nipulation in 1895
n Despite initial conflicts with traditional mainstream medicine includ- ing lawsuits, the two professions finally came to a consensus in the 1970s, and subsequently the National Center for Complementary and Alternative Medicine was set up in the USA
4.11.2.2 Popularity
n There was a resurgence of popularity in alternative medicine in the USA and in many other countries, and relaxation therapy and chiro- practics ranked among the most used forms of alternative medicine
n In the USA, the number of chiropractors rose from 13 000 to 50 000 between 1970 and 1995, owing to the increase in patients seeking al- ternative medicine
4.11.2.3 Licensing and Setting of Standards
n There are 14 accredited chiropractic colleges in the USA
n Candidates need to pass college examinations before practice; the same occurs in Canada and the UK
n The scope of their practice is governed by state law in the USA 4.11.2.4 Scope of Chiropractics
n In practice, most patients seek chiropractors for treatment of muscu- loskeletal system problems
n The most common diagnoses are LBP and neck pain 4.11.2.5 Basic Philosophy
n The traditional thinking of this trade involves the idea of “subluxa- tion” or “misalignment” of the spine, causing abnormal pressure and interfering with nerve function
n These concepts are altered in modern chiropractors who learned about basic science, biomechanics and theories on the neurophysiol- ogy of pain
a 4.11 Brief Outline of “Alternative Medicine” 105
4.11.2.6 “Mobilisation” vs “Manipulation”
n These two terms are often confused
n “Mobilisation”, if passive, means giving an external force to move the joint within its physiological range of motion
n “Manipulation” implies and involves movements induced at the end of the normal ROM and may well lie slightly beyond the usual range, but less than that which creates breaches in spinal integrity
4.11.2.7 Goal of Modern Chiropractics (Using LBP as an Example)
n Pain relief
n Muscle relaxation
n Improved joint ROM
n Some modern chiropractors also give vitamins, nutritional advice, pain killers, order adjunct rehabilitation techniques like ultrasound, cryotherapy, etc.
4.11.2.8 Spinal Manipulative Therapy
n The details of the spinal manipulative therapy (SMT) trade cannot be discussed here, but some techniques used include:
– Long lever arm technique (e.g. enlist the help of the limbs and/or special tables)
– Short lever arm techniques (most commonly used) – Recoil techniques
4.11.2.9 Papers in Support of SMT in Back Pain Treatment
n A more recent trial by Cherkin (N Engl J Med 1998) compared three groups: chiropractic manipulation, McKenzie exercise and education leaflet. He did not find any difference among the three groups with regard to pain recurrence or days off work. The chiropractic group performed significantly better than the minimal intervention group at 4 weeks, but not at 3 months and the 1 year mark
n Triano et al. published a report in Spine 1995 comparing SMT vs edu- cation programme. He noted greater improvement in pain and activ- ity tolerance in the SMT group
n Other support comes mainly from journals on manipulative therapy, e.g. a prospective randomised trial in J Manipulative Physiol Ther 1992 compared TENS, SMT and massage or use of corset. The SMT group showed the greatest improvement at 3 weeks with regard to pain score, patient confidence, and improvement in lumbar flexion
4.11.2.10 Possible Mechanism of SMT (Author’s View)
n The exact mechanism is unknown as written in most textbooks
n However, if the underlying neurophysiological principles (such as autogenic inhibition of skeletal muscles by the induction of Golgi ten- don organ firing) work for strategies like PNF and muscle energy techniques (discussed in Sect. 4.2.5.7), there is no reason why proper stretching of paraspinal muscles with a knowledge of local muscular anatomy and fibre direction need not work for skeletal muscles of the spine, at least in theory
4.11.2.11 Limitations and Contraindications
n Infected field
n Haematoma/bleeding tendency
n Tumours
n Spinal instability and fractures
n Extreme osteoporosis
n Congenital insensitivity to pain
n Caution if congenital ligamentous laxity
n Pre-existing neurology
n Whenever unsure, perform investigations to rule out significant pathology first
4.11.2.12 The Future
n More research is needed to investigate the efficacy and mechanism of chiropractics
n In the author’s own personal view, special caution is needed in per- forming SMT for the normally very mobile cervical spine to prevent damage to the underlying neural structures
4.11.3 Osteopathic Medicine 4.11.3.1 Brief History
n Originated by Andrew Taylor Still who was a physician, and the American School of Osteopathy was founded in 1892
n The word “osteo” means bone, “pathos” means suffer
a 4.11 Brief Outline of “Alternative Medicine” 107
4.11.3.2 Popularity
n In the USA, osteopathic medicine has generally received wide accep- tance since the 1970s. Currently, osteopathic medicine is a recognised profession in all states of the USA
n There are 50,000 osteopathic physicians in the USA, with > 20 colleges of osteopathic medicine
4.11.3.3 Licensing and Setting of Standards
n There are board examinations in the USA set by the National Board of Osteopathic Medical Examiners that have to be passed before licensing. The curriculum includes osteopathic manipulation therapy (OMT) and neuro-musculoskeletal medicine plus a stress on basic science, anatomy and physiology. A final but key element in the cur- riculum is the use of palpatory diagnosis (e.g. including teaching of trigger points)
4.11.3.4 Scope of Osteopathic Medicine
n As there is a stress on the fascia as the “origin” of dysfunction, many patients with diffuse pain and suspected myofascial pain syndrome are referred or volunteer to go to osteopathic practitioners themselves
n The reader can refer to the section on myofascial pain syndrome in Chap. 16
4.11.3.5 Basic Philosophy of Osteopathic Practice
n It is regarded as both a science and an art by osteopathic practi- tioners
n It is a science because throughout the past and present history since its inception, there is a great deal of research on the subject, including that by scientists and physiologists
n It is an art because it is based on very “natural” concepts such as its emphasis on the interplay between human structure and function, and the appreciation that the body has the ability to heal itself, that disease occurs when there is a disruption of the anatomy
4.11.3.6 Basic Philosophy of Osteopathic Manipulation
n Although the name osteopathy has the word “bone” in it, many ma- nipulative strategies are based on the search for fascia as the cause of disease and the place to commence therapy. The aim of manipulation
